| Abstract | Bolesnici koji su podvrgnuti resekcijskom zahvatu na plućima najčešće se klasificiraju kao
status ASA III te već preoperativno imaju oštećenu plućnu funkciju, najčešće koronarnu
prateću bolest i poremećaj imunološkog statusa zbog malignih i kroničnih plućnih bolesti.
Osobitosti torakokirurških operacija su izrazito snažan bolni podražaj, refleksna aktivnost
vaskularnih struktura medijastinuma koja često uzrokuje aritmije, neizbježni poremećaji
ventilacije i cirkulacije, teško održavanje hemodinamske stabilnosti i zadovoljavajuće
oksigenacije bolesnika te snažan stresni odgovor.
Cilj ovog kliničkog istraživanja bio je utvrditi da li epiduralna primjena magnezija u vidu
otopine 10% MgSO4 tijekom torakokirurškog zahvata može modulirati potrebna doze
anestetika, mišićnog relaksansa i analgetika tijekom operativnog zahvata i u prvih 48 sati
postoperativno, smanjiti stresni odgovor te učestalost postoperativnih nuspojava i
komplikacija.
U ovu prospektivnu dvostruko slijepu, placebo-kontroliranu, randomiziranu studiju bili su
uključen bolesnici, podvrgnuti elektivnom torakokirurškom resekcijskom zahvatu na plućima.
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Randomizacijom smo formirali dvije skupine po 35 bolesnika: magenzij skupina ispitanika
koja je tijekom operativnog zahvata uz anesteziološke lijekove primala 10% magnezijev sulfat
(MgSO4) epiduralno i kontrolna skupina koja je uz anesteziološke lijekove epiduralno
primala 0.9% otopinu natrijevog klorida (NaCl) .
Postoperativno, magnezij skupina je epiduralno uz lokalni anestetik i opioid primala i 10%
magnezijev sulfat, dok je kontrolna skupina primala samo lokalni anestetik i opioid.
Tijekom preoperativnog pregleda bolesnici su bili upoznati sa metodama određivanja
intenziteta boli – vizualnom analognom ljestvicom (VAS) i TORDA ljestvicom.
Za sve bolesnike bila je utvrđena: ukupna doza anestetika propofola , mišićnog relaksansa
rokuronijuma i opioida sufentanila primijenjena tijekom operacije; ukupno primijenjena doza
opioida sufentanila i levobupivakaina tijekom 48 sati poslije operacije; razina hormona
stresa- kortizola, prijeoperacije, nakon operacije te svakih 8 sati tijekom prva 24 sata
postoperativno. Posebno je bilježena pojava kardiovaskularnih komplikacija,učestalost
javljanja postoperativne drhtavice, mučnine i povraćanja te pojava bilo kakvih neželjenih
događaja.
U svih naših bolesnika primjena magnezijeva sulfata (MgSO4) se pokazala sigurnom. Niti u
jednog bolesnika epiduralna primjena magnezija nije bila uzrokom cirkulacijske nestabilnosti,
niti se očitovala značajnom hipotenzijom ili bradikardijom. Nije opažena alergijska reakcija
na infuziju magnezija.
Rezultati našega istraživanja pokazali su da dodavanje magnezija u epiduralnu smjesu opioida
sufentanila i lokalnog anestetika levobupivakaina dovodi do učinkovitije intraoperativne i
postoperativne analgezije te manje potrošnje sufentanila i levobupivakaina. Smanjena je
intraoperativna potrošnju anestetika i mišićnog relaksansa uz nižu učestalost javljanja
postoperativne mučnine, povraćanja i drhtavice.
Uz primijenjenu dozu magnezija hemodinamski i respiratorni status bolesnika bio je uredan. Zaključujemo da je zbog navedenih povoljnih učinaka magnezij primijenjen epiduralno
koristan dodatak anesteziološkim lijekovima koji može povoljno utjecati na tijek i ishod
torakokirurškog zahvata. |
| Abstract (english) | Patients undergoing surgical resection of the lungs are generally classified as the American
Society of Anesthesiology (ASA) class III, along with preoperatively impaired pulmonary
function, mostly coronary comorbidity and compromised immune status due to malignant and
chronic lung diseases. Thoracic surgery is associated with severe painful stimuli, reflex
activity of the mediastinum vascular structures that frequently causes arrhythmias,
unavoidable ventilation and circulation disorders, difficulty in maintaining hemodynamic
stability and appropriate oxygenation and strong stress response.
The aim of the present study was to assess the complex effect of epidural magnesium during
thoracic surgery procedure on the overall stress response, modulation of anesthesiologic drug
use and in particular its antinociceptive effect during 48 hours postoperatively in thoracic
surgery patients.
This prospective placebo-controlled randomized study included 70 ASA I-III patients
undergoing elective thoracic surgery resection of the lungs. Seventy patients were randomized
to two groups of 35 patients: magnesium group received epidural 10% magnesium sulfate
(MgSO4) along with anesthesiologic drugs, and control group received epidural 0.9% sodium
chloride (NaCl) solution along with anesthesiologic drugs intraoperatively. Postoperatively,
magnesium group patients were administered epidural 10% magnesium sulfate in addition to
local anesthetic and opioid, whereas control group patients were administered local anesthetic
and opioid alone.
On preoperative examination, patients were informed on the methods of pain intensity
assessment, which included visual analog scale (VAS) for rest and movement (TORDA) .
In all patients, the following parameters were determined: total doses of intraoperatively
administered propofol , rocuronium and sufentanil ; total doses of epidural sufentanil and
levobupivacaine administered during 48 hours postoperatively; levels of the stress hormone
cortisol before operation, after the operation and every 8 hours during first 24 hours
postoperatively. The parameters associated with perioperative course were: systolic and
dyastolic blood pressures monitored continuously for 48 hours; pulse rate monitored
continuously; peripheral oxygen saturation (SaO2), and BIS values; VAS score for rest and
movement every 4 hours; level of sedation immediately after arrival in the ICU ;
cardiovascular complications, respiratory and neurological complications; rate of
postoperative shivering; nausea and vomiting and global patients satisfaction.
Results of the present study indicated that the addition of magnesium in the epidural mixture
of opioid sufentanil and local anesthetic levobupivacaine led to more efficient intraoperative
and postoperative analgesia and to lower utilization of opioid sufentanil and local anesthetic
levobupivacaine. The intraoperative utilization of anesthetic propofol and myorelaxant
rocuronium was decreased, along with a lower rate of postoperative nausea, vomiting and
postoperative shivering. The magnesium dosage used in the study was associated with normal
hemodynamic and respiratory status of the patients. We can conclude that, based on the
favorable effects recorded, epidural magnesium appears to be a useful adjunct to
anesthesiologic drugs, which can exert positive effects on the course and outcome of thoracic
surgery procedures. |
